Adolescent Idiopathic Scoliosis and Back Pain: Difference between revisions

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Back pain most commonly occurs in the lumbar region followed by the thoracic region in AIS for both sexes.<ref name=":1" /><ref name=":2" /><ref name=":3" /> A statistically significant association was found between thoracic pain and thoracic scoliosis in patients with AIS.<ref name=":1" /> . Most AIS patients with back pain reported their pain as moderate to mild intensity<ref name=":1" /><ref name=":2" /><ref name=":3" />. It has also been shown that back pain in AIS lasted longer and occurred more frequently when compared to patients without scoliosis.<ref name=":2" />
Back pain most commonly occurs in the lumbar region followed by the thoracic region in AIS for both sexes.<ref name=":1" /><ref name=":2" /><ref name=":3" /> A statistically significant association was found between thoracic pain and thoracic scoliosis in patients with AIS.<ref name=":1" /> . Most AIS patients with back pain reported their pain as moderate to mild intensity<ref name=":1" /><ref name=":2" /><ref name=":3" />. It has also been shown that back pain in AIS lasted longer and occurred more frequently when compared to patients without scoliosis.<ref name=":2" />


=== Back Pain and Cobb Angle ===
=== Back Pain and [[Cobb's angle|Cobb Angle]] ===
[[File:Cobb angle (Greiner, 2002).png|thumb|'''Fig. 2''' Cobb angle (Greiner, 2002)|376x376px]]
[[File:Cobb angle (Greiner, 2002).png|thumb|'''Fig. 2''' Cobb angle (Greiner, 2002)|376x376px]]
No statistically significant evidence was reported between pain intensity and Cobb angle severity.<ref name=":1" /><ref>Balagué F, Pellisé F. [https://scoliosisjournal.biomedcentral.com/articles/10.1186/s13013-016-0086-7 Adolescent idiopathic scoliosis and back pain.] Scoliosis and spinal disorders. 2016 Dec;11(1):27.</ref> <ref>Rigo M. [https://scoliosisjournal.biomedcentral.com/articles/10.1186/1748-7161-5-S1-O44 Differential diagnosis of back pain in adult scoliosis (non operated patients)]. Scoliosis. 2010 Sep;5(1):O44.</ref> However, it was suggested that patients without pain tend to present with smaller curves; and the incidence and intensity of back pain was higher in more severe curves (>40°-45°).  
No statistically significant evidence was reported between pain intensity and Cobb angle severity.<ref name=":1" /><ref>Balagué F, Pellisé F. [https://scoliosisjournal.biomedcentral.com/articles/10.1186/s13013-016-0086-7 Adolescent idiopathic scoliosis and back pain.] Scoliosis and spinal disorders. 2016 Dec;11(1):27.</ref> <ref>Rigo M. [https://scoliosisjournal.biomedcentral.com/articles/10.1186/1748-7161-5-S1-O44 Differential diagnosis of back pain in adult scoliosis (non operated patients)]. Scoliosis. 2010 Sep;5(1):O44.</ref> However, it was suggested that patients without pain tend to present with smaller curves; and the incidence and intensity of back pain was higher in more severe curves (>40°-45°).  
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== Conservative Treatment ==
== Conservative Treatment ==
Various methods and exercises have been documented to help reduce the Cobb Angle in AIS however as discussed in the above paragraphs this reduction in Cobb Angle does not necessarily lead to reduction in pain.


=== Schroth method ===
=== Schroth method ===
The Schroth method is a set of exercises which is specifically designed for patients with scoliosis, especially for idiopathic scoliosis.<ref name=":7">Berdishevsky H, Lebel VA, Bettany-Saltikov J, Rigo M, Lebel A, Hennes A, Romano M, Białek M, M’hango A, Betts T, de Mauroy JC. [https://www.ncbi.nlm.nih.gov/pubmed/27525315 Physiotherapy scoliosis-specific exercises–a comprehensive review of seven major schools]. Scoliosis and spinal disorders. 2016 Dec;11(1):20.</ref>  It was developed by Katharina Schroth in Germany. Schroth method aims at preventing curve progression before the end of growth with the following goals<ref name=":8">Kim MJ, Park DS. [http://www.jptrs.org/journal/view.html?doi=10.14474/ptrs.2017.6.3.113 The effect of Schroth’s three-dimensional exercises in combination with respiratory muscle exercise on Cobb’s angle and pulmonary function in patients with idiopathic scoliosis]. Physical Therapy Rehabilitation Science. 2017 Sep 30;6(3):113-9.</ref>:
The Schroth method is a set of exercises which is specifically designed for patients with scoliosis, especially for idiopathic scoliosis.<ref name=":7">Berdishevsky H, Lebel VA, Bettany-Saltikov J, Rigo M, Lebel A, Hennes A, Romano M, Białek M, M’hango A, Betts T, de Mauroy JC. [https://www.ncbi.nlm.nih.gov/pubmed/27525315 Physiotherapy scoliosis-specific exercises–a comprehensive review of seven major schools]. Scoliosis and spinal disorders. 2016 Dec;11(1):20.</ref>  It was developed by Katharina Schroth in Germany. Schroth method aims at preventing curve progression before the end of growth with the following goals<ref name=":8">Kim MJ, Park DS. [http://www.jptrs.org/journal/view.html?doi=10.14474/ptrs.2017.6.3.113 The effect of Schroth’s three-dimensional exercises in combination with respiratory muscle exercise on Cobb’s angle and pulmonary function in patients with idiopathic scoliosis]. Physical Therapy Rehabilitation Science. 2017 Sep 30;6(3):113-9.</ref><ref>Schreiber S, Parent EC, Moez EK, Hedden DM, Hill D, Moreau MJ, Lou E, Watkins EM, Southon SC. [https://www.ncbi.nlm.nih.gov/pubmed/26413145 The effect of Schroth exercises added to the standard of care on the quality of life and muscle endurance in adolescents with idiopathic scoliosis—an assessor and statistician blinded randomized controlled trial:“SOSORT 2015 Award Winner”]. Scoliosis. 2015 Dec;10(1):24.</ref><ref>Lee HJ, Seong HD, Bae YH, Jang HY, Chae SH, Kim KH, Lee SM. [https://www.ncbi.nlm.nih.gov/pubmed/27821972 Effect of the Schroth method of emphasis of active holding on Cobb’s angle in patients with scoliosis: a case report.] Journal of physical therapy science. 2016;28(10):2975-8.</ref>:
* Proactive spinal corrections to avoid surgery
* Proactive spinal corrections to avoid surgery
* Postural training to avoid or decelerate progression
* Postural training to avoid or decelerate progression
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* Prevention and coping strategies for pain
* Prevention and coping strategies for pain


==== Evidence for the effectiveness of Schroth method exercises ====
=== Braces ===
Schreiber et al.<ref>Schreiber S, Parent EC, Moez EK, Hedden DM, Hill D, Moreau MJ, Lou E, Watkins EM, Southon SC. [https://www.ncbi.nlm.nih.gov/pubmed/26413145 The effect of Schroth exercises added to the standard of care on the quality of life and muscle endurance in adolescents with idiopathic scoliosis—an assessor and statistician blinded randomized controlled trial:“SOSORT 2015 Award Winner”]. Scoliosis. 2015 Dec;10(1):24.</ref> did a randomised controlled trial (RCT) which suggested that Schroth method exercises with standard care improved pain in patients with AIS over a 6-month intervention. [[File:Exercise prescription for each curve type (Schreiber et al., 2015).png|thumb|521x521px|'''Fig. 3''' Exercise prescription for each curve type (Schreiber et al., 2015)]]
In a systematic review, few studies measured back pain in patients with AIS this study suggested that bracing did not have an effect on back pain in long term<ref>Negrini, S., Minozzi, S., Bettany-Saltikov, J., Chockalingam, N., Grivas, T., Kotwicki, T., Maruyama, T., Romano, M. and Zaina, F. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010663.pub2/pdf/standard Braces for idiopathic scoliosis in adolescents]. ''Cochrane Database of Systematic Reviews''. . 2015. Issue 6, art. no.: CD006850. </ref>.
Strengths
* The assessors and the statistician were blinded to the treatment allocation
* Standardised treatment by developing the classification and exercise prescription algorithms
* Specific exercise prescription for each curve type (fig. 3)


Limitations
Another systematic review suggested that bracing has no influence on back pain when compared to the observation group, however, conflicting evidence was reported in this review.<ref name=":11">Balagué F, Pellisé F. [https://scoliosisjournal.biomedcentral.com/articles/10.1186/s13013-016-0086-7 Adolescent idiopathic scoliosis and back pain.] Scoliosis and spinal disorders. 2016 Dec;11(1):27.</ref>
* Only overall pain was measured
* The therapists, patients and accessors could not be blinded to the exercises in which they were involved
* Pain is a subjective outcome
* RCT is not at the top of the hierarchy of evidence


Lee et al<ref>Lee HJ, Seong HD, Bae YH, Jang HY, Chae SH, Kim KH, Lee SM. [https://www.ncbi.nlm.nih.gov/pubmed/27821972 Effect of the Schroth method of emphasis of active holding on Cobb’s angle in patients with scoliosis: a case report.] Journal of physical therapy science. 2016;28(10):2975-8.</ref> did a case study which showed a decrease in pain and Cobb’s angle in all subjects after applying the Schroth method with emphasis on active holding. Table 3 shows the PICO model of the study and table 4 shows the results of it.
=== Osteopathic manipulation ===
There is currently no evidence to support osteopathic manipulation as the treatment for AIS<ref name=":11" />.


=== Breathing retraining and exercises ===
=== Taping ===
There are evidence suggesting the use of breathing exercises as a treatment for chronic LBP.<ref name=":9">Anderson, B. E. and Bliven, K. C. H.The Use of Breathing Exercises in the Treatment of Chronic, Nonspecific Low Back Pain. ''Journal of Sport Rehabilitation''. 2017;26 (5), pp. 452-458.</ref> This review included 3 RCTs of medium quality with reference to the Physiotherapy Evidence Database (PEDro) scale.<ref name=":10">Liao, C., Xie, G., Tsauo, J., Chen, H. and Liou, T. Efficacy of extracorporeal shock wave therapy for knee tendinopathies and other soft tissue disorders: a meta-analysis of randomized controlled trials. ''BMC Musculoskeletal Disorders''. 2018;19 (278)</ref> The searches were conducted across 5 databases and 10 years (2005-2015). However, one thing to note is that the patients included in the studies may not have scoliosis and this review is not specific to adolescents.
It has been suggested that [[Kinesiology Taping|Kinesio Taping]] decreases back pain and increases quality of life in patients with type 1 AIS under the Lenke classification of scoliosis. This is a RCT and the only study on Kinesio Taping for AIS. Therefore, there is insufficient evidence.<ref>Atici, Y., Aydin, C., Atici, A., Buyukkuscu, M., Arikan, Y. and Balioglu, M.The effect of Kinesio taping on back pain in patients with Lenke Type 1 adolescent idiopathic scoliosis: A randomized controlled trial. ''Acta Orthopaedica et Traumatologica Turcica''. 2017;51 (3), pp.191-196.</ref>


===== Rotational Angular Breathing (RAB) =====
=== Surgical Treatment for AIS ===
[[File:RAB (Berdishevsky et al., 2016).png|thumb|568x568px|'''Fig. 4''' Before (A) and during (B) rotation angular breathing (RAB). The arrows represent directional breathing used to fill the collapsed lungs with air and reshape the thorax (B) (Berdishevsky et al., 2016)]]
Surgery may be recommended if the scoliosis is worsening and other treatments are ineffective, or if the scoliosis is severe and the adolescent has stopped growing.  
Schroth method is considered to be more effective than manual treatments because of its three-dimensional nature and its rotational angular breathing (RAB) component.<ref name=":8" /> It helps in vertebral and rib cage derotation and in increasing vital capacity.<ref name=":7" />


RAB helps expand the ribcage by pushing the ribs ‘sideways and backwards’ and helps return the vertebrae closer to their normal, untwisted position<ref name=":7" /> (fig. 4)
Surgical treatments are indicated when the Cobb angle is greater than 45 to 50 degrees.<ref name=":12">Maruyama T, Takeshita K. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3676291/ Surgery for idiopathic scoliosis: currently applied techniques]. Clinical medicine. Pediatrics. 2009 Jan;3:CMPed-S2117.</ref> Posterior fusion with instrumentation is usually performed for idiopathic scoliosis.<ref name=":12" />
{{#ev:youtube|https://youtu.be/dyNrxq-PKmQ|||||start=16}}
Equipment such as wall bars and elastic bands can also be used with RAB as part of the Schroth’s exercises. It can be done in different position like forward bending, sitting and side-lying.
{{#ev:youtube|https://www.youtube.com/watch?v=xGUojrDPkP4}}
{{#ev:youtube|https://www.youtube.com/watch?v=cmWYhpT6Qfk}}
===== '''Respiratory muscle exercises''' =====
The RCT done by Kim et al has shown that breathing muscle strengthening can improve both Cobb angle and respiratory function.<ref name=":8" /> Table 5 shows the PICO model of the study and table 6 shows the results of it.
{{#ev:youtube|https://www.youtube.com/watch?v=EvqzAPqh6HE|||||start=60}}
<nowiki>*</nowiki>SD=statistical difference


Strength
== Conclusion ==
* PEDro scale: 7/10 (high quality<ref name=":10" />)
Back pain is very common in adolescent idiopathic scoliosis which can effect the quality of life in these patients. There are many contributing factors for the presence of back pain in AIS, including altered anatomy and breathing pattern. Current evidence mainly suggests the use of Schroth's method with rotational angular breathing as a treatment for back pain in adolescent idiopathic scoliosis.
Limitations
* Unknown external validity and clinical significance
** Unknown minimally clinical important difference for Cobb angle
* High risk of type 2 error
** Small sample size
* Questionable internal validity
** Unknown blinding conditions
* Lack of evidence for using SpiroTiger as respiratory muscle exercises
* Uncertain relationship between Cobb angle and pain, although breathing exercises have been used to treat LBP in other studies<ref name=":9" />
 
===== '''Braces''' =====
Negrini et al.<ref>Negrini, S., Minozzi, S., Bettany-Saltikov, J., Chockalingam, N., Grivas, T., Kotwicki, T., Maruyama, T., Romano, M. and Zaina, F. Braces for idiopathic scoliosis in adolescents. ''Cochrane Database of Systematic Reviews''. [Online]. 2015. Issue 6, art. no.: CD006850. Available at: <nowiki>https://doi.org/10.1002/14651858.CD006850.pub3</nowiki>. [Accessed on 23<sup>rd</sup> May 2019].</ref> did a systematic review on the use of braces on back pain in AIS. Out of the seven studies, there is only one that measured back pain and it suggested that bracing did not have an effect on back pain in long term. However, the evidence included in this review is of very low quality.
 
Another systematic review done by Balagué et al<ref name=":11">Balagué, F. and Pellisé, F. Adolescent idiopathic scoliosis and back pain. ''Scoliosis and Spinal Disorders''. 2016:11 (1), pp. 27.</ref> suggested that bracing has no influence on back pain when compared to the observation group, however, conflicting evidence was reported in this review.
 
===== '''Osteopathic manipulation''' =====
There is currently no evidence to support osteopathic manipulation as the treatment for AIS<ref name=":11" />.


===== '''Taping''' =====
== Resources ==
Atici et al<ref>Atici, Y., Aydin, C., Atici, A., Buyukkuscu, M., Arikan, Y. and Balioglu, M.The effect of Kinesio taping on back pain in patients with Lenke Type 1 adolescent idiopathic scoliosis: A randomized controlled trial. ''Acta Orthopaedica et Traumatologica Turcica''. 2017;51 (3), pp.191-196.</ref>  suggested Kinesio Taping decreases back pain and increases the QoL in patients with type 1 AIS under the Lenke classification of scoliosis. This is a RCT and the only study on Kinesio Taping for AIS. Therefore, there is insufficient evidence.
[https://www.nhs.uk/conditions/scoliosis/treatment-in-children/ NHS Scoliosis]


=== Surgical Treatment for AIS ===
[https://www.srs.org/patients-and-families/conditions-and-treatments/parents/scoliosis/adolescent-idiopathic-scoliosis Scoliosis Research Society]
Surgery may be recommended if the scoliosis is worsening and other treatments are ineffective, or the scoliosis is severe and the adolescent has stopped growing.<ref>NHS. ''Treatment in children - Scoliosis''. [Online]. Available at: <nowiki>https://www.nhs.uk/conditions/scoliosis/treatment-in-children/</nowiki>. [Accessed on 22nd May, 2019].</ref> In general, surgical treatments are indicated when the Cobb angle (degree of curvature of the spine) is greater than 45 to 50 degrees.<ref name=":12">Maruyama, T. and Takeshita K. Surgery for Idiopathic Scoliosis: Currently Applied Techniques. ''Clinical Medicine: Pediatrics''. 2009;3 pp. 39-44.</ref> Posterior fusion with instrumentation is usually performed for idiopathic scoliosis.<ref name=":12" />
 
== Conclusion ==
Back pain is very common in adolescent idiopathic scoliosis which can affects the quality of life of patients. There are many contributing factors for the presence of back pain in AIS, including altered anatomy and breathing pattern. Current evidence mainly suggests the use of Schroth's method with rotational angular breathing as a treatment for back pain in  adolescent idiopathic scoliosis.


== References ==
== References ==

Revision as of 19:29, 20 August 2019

Introduction[edit | edit source]

Fig. 1 A patient with AIS and her X-ray image of her spine (Paria et al., 2015).

Scoliosis can be described as an abnormal curvature of the spine. The Cobb angle (fig.2) and Risser sign are measures commonly used to assess the degree and progression of the curvature. Adolescent idiopathic scoliosis (AIS) is a type of idiopathic scoliosis.

Prevalence of AIS[edit | edit source]

AIS is a common disease with an overall prevalence of 0.47-5.2 % in the current literature[1]. It develops at the age of 11-18 and takes up 90% of idiopathic scoliosis cases in children. The female to male ratio ranges from 1.5:1 to 3:1 and increases substantially with age. Genetic factors play a role as well. [1]

Back Pain in AIS[edit | edit source]

Back pain is approximately twice as prevalent in patients with AIS compared to non-scoliosis patients [2][3][4]

Back pain most commonly occurs in the lumbar region followed by the thoracic region in AIS for both sexes.[2][3][4] A statistically significant association was found between thoracic pain and thoracic scoliosis in patients with AIS.[2] . Most AIS patients with back pain reported their pain as moderate to mild intensity[2][3][4]. It has also been shown that back pain in AIS lasted longer and occurred more frequently when compared to patients without scoliosis.[3]

Back Pain and Cobb Angle[edit | edit source]

Fig. 2 Cobb angle (Greiner, 2002)

No statistically significant evidence was reported between pain intensity and Cobb angle severity.[2][5] [6] However, it was suggested that patients without pain tend to present with smaller curves; and the incidence and intensity of back pain was higher in more severe curves (>40°-45°).

The Scoliosis Research Society (SRS) suggested that the presence of back pain may due to reduced trunk strength or hamstring flexibility. However, no evidence supports this statement.

Back Pain and Quality of Life in AIS[edit | edit source]

Lower back pain (LBP) in AIS patients can cause deterioration of patients’ quality of life. Other than pain, patients' self-image such as attitude their own physical appearance is also one of the contributing factors of the deterioration of quality of life.[7]

Dysfunctional respiratory function in AIS[edit | edit source]

Dysfunctional and asymmetrical breathing pattern often presents in patients with scoliosis.[8] Trunk rotation is increased as a result of inspiratory breathing forces being directed downwards to the convexity of the spinal curvature.[8] There is also a linkage between dysfunctional breathing and LBP or neck pain.[9][10]

Conservative Treatment[edit | edit source]

Various methods and exercises have been documented to help reduce the Cobb Angle in AIS however as discussed in the above paragraphs this reduction in Cobb Angle does not necessarily lead to reduction in pain.

Schroth method[edit | edit source]

The Schroth method is a set of exercises which is specifically designed for patients with scoliosis, especially for idiopathic scoliosis.[11] It was developed by Katharina Schroth in Germany. Schroth method aims at preventing curve progression before the end of growth with the following goals[12][13][14]:

  • Proactive spinal corrections to avoid surgery
  • Postural training to avoid or decelerate progression
  • Information to support the decision-making process
  • Home-exercise program
  • Support network
  • Prevention and coping strategies for pain

Braces[edit | edit source]

In a systematic review, few studies measured back pain in patients with AIS this study suggested that bracing did not have an effect on back pain in long term[15].

Another systematic review suggested that bracing has no influence on back pain when compared to the observation group, however, conflicting evidence was reported in this review.[16]

Osteopathic manipulation[edit | edit source]

There is currently no evidence to support osteopathic manipulation as the treatment for AIS[16].

Taping[edit | edit source]

It has been suggested that Kinesio Taping decreases back pain and increases quality of life in patients with type 1 AIS under the Lenke classification of scoliosis. This is a RCT and the only study on Kinesio Taping for AIS. Therefore, there is insufficient evidence.[17]

Surgical Treatment for AIS[edit | edit source]

Surgery may be recommended if the scoliosis is worsening and other treatments are ineffective, or if the scoliosis is severe and the adolescent has stopped growing.

Surgical treatments are indicated when the Cobb angle is greater than 45 to 50 degrees.[18] Posterior fusion with instrumentation is usually performed for idiopathic scoliosis.[18]

Conclusion[edit | edit source]

Back pain is very common in adolescent idiopathic scoliosis which can effect the quality of life in these patients. There are many contributing factors for the presence of back pain in AIS, including altered anatomy and breathing pattern. Current evidence mainly suggests the use of Schroth's method with rotational angular breathing as a treatment for back pain in adolescent idiopathic scoliosis.

Resources[edit | edit source]

NHS Scoliosis

Scoliosis Research Society

References[edit | edit source]

  1. ↑ 1.0 1.1 Konieczny MR, Senyurt H, Krauspe R. Epidemiology of adolescent idiopathic scoliosis. Journal of children's orthopaedics. 2012 Dec 11;7(1):3-9.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Théroux J, Le May S, Fortin C, Labelle H. Prevalence and management of back pain in adolescent idiopathic scoliosis patients: a retrospective study. Pain Research and Management. 2015;20(3):153-7.
  3. ↑ 3.0 3.1 3.2 3.3 Sato T, Hirano T, Ito T, Morita O, Kikuchi R, Endo N, Tanabe N. Back pain in adolescents with idiopathic scoliosis: epidemiological study for 43,630 pupils in Niigata City, Japan. European Spine Journal. 2011 Feb 1;20(2):274-9.
  4. ↑ 4.0 4.1 4.2 Joncas, J., Labelle, H., Poitras, B., Duhaime, M., Rivard, C. and Le Blanc, R. Dorso-lumbal pain and idiopathic scoliosis in adolescence. Annales de Chirurgie. 1996;50 (8), pp. 637-640.
  5. ↑ Balagué F, Pellisé F. Adolescent idiopathic scoliosis and back pain. Scoliosis and spinal disorders. 2016 Dec;11(1):27.
  6. ↑ Rigo M. Differential diagnosis of back pain in adult scoliosis (non operated patients). Scoliosis. 2010 Sep;5(1):O44.
  7. ↑ Makino T, Kaito T, Kashii M, Iwasaki M, Yoshikawa H. Low back pain and patient-reported QOL outcomes in patients with adolescent idiopathic scoliosis without corrective surgery. Springerplus. 2015 Dec 1;4(1):397.
  8. ↑ 8.0 8.1 Weiss HR, Moramarco MM, Borysov M, Ng SY, Lee SG, Nan X, Moramarco KA. Postural rehabilitation for adolescent idiopathic scoliosis during growth. Asian spine journal. 2016 Jun;10(3):570.
  9. ↑ Bradley H, Esformes JD. Breathing pattern disorders and functional movement. International journal of sports physical therapy. 2014 Feb;9(1):28.
  10. ↑ Kiesel K, Rhodes T, Mueller J, Waninger A, Butler R. Development of a screening protocol to identify individuals with dysfunctional breathing. International journal of sports physical therapy. 2017 Oct;12(5):774.
  11. ↑ Berdishevsky H, Lebel VA, Bettany-Saltikov J, Rigo M, Lebel A, Hennes A, Romano M, Białek M, M’hango A, Betts T, de Mauroy JC. Physiotherapy scoliosis-specific exercises–a comprehensive review of seven major schools. Scoliosis and spinal disorders. 2016 Dec;11(1):20.
  12. ↑ Kim MJ, Park DS. The effect of Schroth’s three-dimensional exercises in combination with respiratory muscle exercise on Cobb’s angle and pulmonary function in patients with idiopathic scoliosis. Physical Therapy Rehabilitation Science. 2017 Sep 30;6(3):113-9.
  13. ↑ Schreiber S, Parent EC, Moez EK, Hedden DM, Hill D, Moreau MJ, Lou E, Watkins EM, Southon SC. The effect of Schroth exercises added to the standard of care on the quality of life and muscle endurance in adolescents with idiopathic scoliosis—an assessor and statistician blinded randomized controlled trial:“SOSORT 2015 Award Winner”. Scoliosis. 2015 Dec;10(1):24.
  14. ↑ Lee HJ, Seong HD, Bae YH, Jang HY, Chae SH, Kim KH, Lee SM. Effect of the Schroth method of emphasis of active holding on Cobb’s angle in patients with scoliosis: a case report. Journal of physical therapy science. 2016;28(10):2975-8.
  15. ↑ Negrini, S., Minozzi, S., Bettany-Saltikov, J., Chockalingam, N., Grivas, T., Kotwicki, T., Maruyama, T., Romano, M. and Zaina, F. Braces for idiopathic scoliosis in adolescents. Cochrane Database of Systematic Reviews. . 2015. Issue 6, art. no.: CD006850.
  16. ↑ 16.0 16.1 Balagué F, Pellisé F. Adolescent idiopathic scoliosis and back pain. Scoliosis and spinal disorders. 2016 Dec;11(1):27.
  17. ↑ Atici, Y., Aydin, C., Atici, A., Buyukkuscu, M., Arikan, Y. and Balioglu, M.The effect of Kinesio taping on back pain in patients with Lenke Type 1 adolescent idiopathic scoliosis: A randomized controlled trial. Acta Orthopaedica et Traumatologica Turcica. 2017;51 (3), pp.191-196.
  18. ↑ 18.0 18.1 Maruyama T, Takeshita K. Surgery for idiopathic scoliosis: currently applied techniques. Clinical medicine. Pediatrics. 2009 Jan;3:CMPed-S2117.
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